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Non-contrast CT scan of the head
Temporal artery biopsy
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This elderly woman with temporal headache, visual changes, fever, and elevated ESR likely has giant cell arteritis. The most appropriate next step in management for patients with suspected or confirmed giant cell arteritis is initiation of high-dose intravenous corticosteroid therapy to prevent visual loss.Giant cell arteritis, formerly referred to as temporal arteritis, is a medium to large vessel vasculitis usually affecting the branches of the external carotid artery. The disease almost exclusively occurs in patients over the age of 50, with women more likely to be affected. Patients with polymyalgia rheumatica are at particularly elevated risk. Classic symptoms include fever, persistent, often temporal or occipital headache, jaw claudication, and visual changes. Exam often demonstrates tenderness to palpation of the scalp overlying the temporal artery. Laboratory studies generally reveal elevated inflammatory markers such as ESR and C reactive protein. As branches of the external carotid artery, namely the ophthalmic artery, become inflamed, the arterial lumen narrows and ischemia develops. This can lead to visual changes and blindness in patients that are not treated. For this reason, patients with suspected giant cell arteritis are treated with high dose steroid therapy prior to confirmation with temporal artery biopsy.Caylor et. al review the pathophysiology, diagnosis and management of giant cell arteritis. They note the particular association of this disease with polymyalgia rheumatica, and recommend that patients with suspected giant cell arteritis be treated with high dose steroids prior to confirmation of the diagnosis with biopsy.Incorrect Answers:Answer 2: Lumbar puncture would be indicated if idiopathic intracranial hypertension was suspected as the cause of this patient's headache. While this condition may also cause visual disturbances, it is generally in both eyes, and most commonly affects younger, obese females. Answer 3: Non-contrast CT scan of the head would be indicated if subarachnoid hemorrhage or other intracranial bleed were suspected as the cause of this patient's headache. However, this patient's history and presentation are more suggestive of giant cell arteritis. CT imaging is not used to diagnose giant cell arteritis. Answer 4: Oral sumatriptan may be appropriate if this patient were presenting with a typical migraine type headache. However, this patient's age, history, and presentation make giant cell arteritis a more likely and urgent diagnosis. Answer 5: Temporal artery biopsy is indicated in this patient to confirm the diagnosis of giant cell arteritis. However, due to the risk of visual loss, it is imperative that this patient first be treated with high dose corticosteroid therapy. Biopsy should not delay or prevent treatment.Bullet Summary: For patients with suspected giant cell arteritis, the most appropriate next step in management is high dose intravenous corticosteroid therapy prior to confirmation of the diagnosis with biopsy.
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